Oncology Patients With
Cylinders for Intracavitary
of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy
Injection of Chromic Phosphate
Omental Pedicle "J"
With Bilateral Inguinal
Lymph Node Dissection
Vulva With Gracilis Myocutaneous Flaps
Flap and Vertical Rectus
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina
"J" Pouch Rectal
Omental "J" Flap
Continent Urostomy (Miami Pouch)
Gracilis Dynamic Anal
System Versus Skin Grafting
Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina
of Hemorrhage in Gynecologic Surgery
of the Punctured
of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery
Suspension of the Vagina
Not to Do in Case of Pelvic Hemorrhage
Associated With Abdominal Pregnancy
Pedicle "J" Flap
An omental "J" flap provides (1) a nonirradiated vascular
pedicle flap to cover intestinal anastomoses and (2) vesicovaginal-rectovaginal
fistula repairs to form a lid on the inlet of the true pelvis after
exenteration and to form a cylinder for a neovagina.
The purpose of
this operation is to create a flap from the omentum by transecting
the omentum from its attachments to the stomach, leaving enough branches
of the left gastroepiploic vessels to provide an adequate blood supply
for the flap.
Physiologic Changes. Irradiation produces
obliterative endarteritis, ischemia, and fibrosis, all of which retard
healing. By applying a vascular pedicle that has not been irradiated,
the surgeon attempts to reverse some of the ischemia present in the
irradiated tissue by promoting capillary and arterial ingrowth from
the pedicle flap's blood supply. In addition, when the inlet to the
true pelvis has been blocked by an omental lid, the small bowel is
prevented from dropping into the denuded true pelvis after an extensive
operation. Therefore, the possibility of intestinal obstruction and
fistula formation is reduced. The omentum has a copious blood supply.
Therefore, it is an excellent recipient of a skin graft for a neovagina.
Points of Caution. The short gastric vascular arcades
to the omentum must be identified on the greater curvature of the stomach
prior to initiating the procedure to ensure an adequate blood supply
from the gastroepiploic artery remains for the proposed omental flap.
The flap should be designed so the stomach is not pulled into the lower
abdomen. The flap should not be placed on tension.
This operation is performed
in conjunction with other radical pelvic surgery. Therefore,
the appropriate incision for the initial procedure is adequate
for the omental "J" flap. It is extremely difficult to perform
the omental J flap through a transverse or Pfannenstiel incision,
so a midline incision extended around the umbilicus is preferred.
The design of the flap prior
to transecting the omentum is essential. A centimeter ruler and
unfolded sponge are helpful in determining the appropriate length
needed for the flap to reach the pelvis without tension. A check
of the vascular arcades should be made to ensure that an ample
blood supply is entering the base of the flap. Generally, the
transection of the omentum is started at the hepatic flexure
of the colon and proceeds from the patient's right to her left.
The omentum is opened in avascular areas
with a small Kelly or Metzenbaum scissors. The vascular bridges
between these openings can be doubly clamped with Kelly clamps,
incised, and tied with 2-0 suture.
An alternative to Kelly clamps
is the automatic LDS (linear dissecting) stapler (United States
Surgical Corp.). This device clamps the vascular bridges between
the openings in the omentum with the jaws of the stapler, applies
two stainless steel clips, and activates a scalpel within the
stapler to cut between the steel clips. It is a valuable, and
The omental flap is completed. It can be
moved into the pelvis as a cover for a suture line or a pelvic